Leveraging a Longitudinally Linked Dataset to Assess Recurrence of Severe Maternal Morbidity.

OBJECTIVES: Among those with a severe maternal morbidity (SMM) event and a subsequent birth, we examined how the risk of a second SMM event varied by patient characteristics and intrapartum hospital utilization. METHODS: We used a Massachusetts population-based dataset that longitudinally linked in-state births, hospital discharge records, prior and subsequent births, and non-birth-related hospital utilizations for birthing individuals and their children from January 1, 1999, to December 31, 2018, representing 1,460,514 births by 907,530 birthing people. We restricted our study sample to 2,814 people who had their first SMM event associated with a singleton birth and gave birth a second time within the study period. Our outcome measure was recurrence of SMM in the second birth. We calculated the prevalence of SMM at second birth, compared SMM conditions between births, and estimated the adjusted risk ratios and 95% confidence intervals for having an SMM event at second birth among those who had an SMM at the first birth. We also examined overall hospital utilization including inpatient admissions, emergency room visits, and observational stays, and hospital utilization by interpregnancy intervals (IPIs) between the first and second birth. RESULTS: There were 2,814 birthing people with at least one birth after the first SMM singleton birth. Among those, 198 (7.0%) had a subsequent SMM. The percentage of people with a second SMM event varied by age, race/ethnicity, insurance, IPI, and history of hypertension at first case of SMM (all p < .05). Between births, people with a second SMM event had significantly higher proportions of inpatient admissions (60.1% vs. 33.2.0%; p < .001), emergency room visits (71.7% vs. 57.7%; p < .001), and observational stays (35.4% vs. 19.5%; p < .001) compared with those who did not experience a second SMM event. CONCLUSION: Hospital utilization after a birth with SMM might indicate an elevated risk of a second SMM event. Providers should counsel their patients about prevention and warning signs.

Strategies to Promote Maternal Health Equity: The Role of Perinatal Quality Collaboratives.

Perinatal quality improvement is a method to increase obstetric safety and promote health equity. Increasing trends of maternal deaths, life-threatening complications of pregnancy, and persistent racial inequities are unacceptable. This Narrative Review examines the role and strategies of perinatal quality initiatives and collaboratives to deliver safe and equitable maternity care and the evidence of demonstrated success. Key strategies to promote maternal equity through perinatal quality include communicating equity as a priority through leadership, leveraging data and enhancing surveillance, engaging in strategic partnerships, engaging community, educating clinicians, and implementing practice recommendations through collaboration.

Development of a Maternal Equity Safety Bundle to Eliminate Racial Inequities in Massachusetts.

OBJECTIVE: The PNQIN (Perinatal-Neonatal Quality Improvement Network of Massachusetts) sought to adapt the Reduction of Peripartum Racial and Ethnic Disparities Conceptual Framework and Maternal Safety Consensus Bundle by selecting and defining measures to create a bundle to address maternal health inequities in Massachusetts. This study describes the process of developing consensus-based measures to implement the PNQIN Maternal Equity Bundle across Massachusetts hospitals participating in the Alliance for Innovation on Maternal Health Initiative. METHODS: Our team used a mixed-methods approach to create the PNQIN Maternal Equity Bundle through consensus including a literature review, expert interviews, and a modified Delphi process to compile, define, and select measures to drive maternal equity-focused action. Stakeholders were identified by purposive and snowball sampling and included obstetrician-gynecologists, midwives, nurses, epidemiologists, and racial equity scholars. Dedoose 9.0 was used to complete an inductive analysis of interview transcripts. A modified Delphi method was used to reach consensus on recommendations and measures for the PNQIN Maternal Equity Bundle. RESULTS: Twenty-five interviews were completed. Seven themes emerged, including the need for 1) data stratification by race, ethnicity and language; 2) performance of a readiness assessment; 3) culture shift toward equity; 4) inclusion of antiracism and bias training; 5) addressing challenges of nonacademic hospitals; 6) a life-course approach; and 7) selection of timing of implementation. Twenty initial quality measures (structure, process, and outcome) were identified through expert interviews. Group consensus supported 10 measures to be incorporated into the bundle. CONCLUSION: Structure, process, and outcome quality measures were selected and defined for a maternal equity safety bundle that seeks to create an equity-focused infrastructure and equity-specific actions at birthing facilities. Implementation of an equity-focused safety bundle at birthing facilities may close racial gaps in maternal outcomes.

Scaling and sustaining COVID-19 vaccination through meaningful community engagement and care coordination for underserved communities: hybrid type 3 effectiveness-implementation sequential multiple assignment randomized trial.

BACKGROUND: COVID-19 inequities are abundant in low-income communities of color. Addressing COVID-19 vaccine hesitancy to promote equitable and sustained vaccination for underserved communities requires a multi-level, scalable, and sustainable approach. It is also essential that efforts acknowledge the broader healthcare needs of these communities including engagement in preventive services. METHODS: This is a hybrid type 3 effectiveness-implementation study that will include a multi-level, longitudinal, mixed-methods data collection approach designed to assess the sustained impact of a co-created multicomponent strategy relying on bidirectional learning, shared decision-making, and expertise by all team members. The study capitalizes on a combination of implementation strategies including mHealth outreach with culturally appropriate messaging, care coordination to increase engagement in high priority preventive services, and the co-design of these strategies using community advisory boards led by Community Weavers. Community Weavers are individuals with lived experience as members of an underserved community serving as cultural brokers between communities, public health systems, and researchers to co-create community-driven, culturally sensitive public health solutions. The study will use an adaptive implementation approach operationalized in a sequential multiple assignment randomized trial design of 300 participants from three sites in a Federally Qualified Health Center in Southern California. This design will allow examining the impact of various implementation strategy components and deliver more intensive support to those who benefit from it most. The primary effectiveness outcomes are COVID-19 vaccine completion, engagement in preventive services, and vaccine confidence. The primary implementation outcomes are reach, adoption, implementation, and maintenance of the multicomponent strategy over a 12-month follow-up period. Mixed-effects logistic regression models will be used to examine program impacts and will be triangulated with qualitative data from participants and implementers. DISCUSSION: This study capitalizes on community engagement, implementation science, health equity and communication, infectious disease, and public health perspectives to co-create a multicomponent strategy to promote the uptake of COVID-19 vaccination and preventive services for underserved communities in San Diego. The study design emphasizes broad engagement of our community and clinic partners leading to culturally sensitive and acceptable strategies to produce lasting and sustainable increases in vaccine equity and preventive services engagement. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05841810 May 3, 2023.

Preconception and perinatal hospitalizations as indicators of risk for severe maternal morbidity in primiparas.

BACKGROUND: Severe maternal morbidity includes unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman's health. A statewide longitudinally linked database was used to examine hospitalization during and before pregnancy for birthing people with severe maternal morbidity at delivery. OBJECTIVE: This study aimed to examine the association between hospital visits during pregnancy and 1 to 5 years before pregnancy and severe maternal morbidity at delivery. STUDY DESIGN: This study was a retrospective, population-based cohort analysis of the Massachusetts Pregnancy to Early Life Longitudinal database between January 1, 2004, and December 31, 2018. Nonbirth hospital visits, including emergency department visits, observational stays, and hospital admissions during pregnancy and 5 years before pregnancy, were identified. The diagnoses for hospitalizations were categorized. We compared medical conditions leading to antecedent, nonbirth hospital visits among primiparous birthing individuals with singleton births with and without severe maternal morbidity, excluding transfusions. RESULTS: Of 235,398 birthing individuals, 2120 had severe maternal morbidity, a rate of 90.1 cases per 10,000 deliveries, and 233,278 did not have severe maternal morbidity. Compared with 4.3% of patients without severe maternal morbidity, 10.4% of patients with severe maternal morbidity were hospitalized during pregnancy. In multivariable analysis, there was a 31% increased risk of hospital admission during the prenatal period, a 60% increased risk of hospital admission in the year before pregnancy, and a 41% increased risk of hospital admission in 2 to 5 years before pregnancy. Compared with 9.8% of non-Hispanic White birthing people, 14.9% of non-Hispanic Black birthing people with severe maternal morbidity experienced a hospital admission during pregnancy. For those with severe maternal morbidity, prenatal hospitalization was most common for those with endocrine (3.6%) or hematologic (3.3%) conditions, with the largest differences between those with and without severe maternal morbidity for musculoskeletal (relative risk, 9.82; 95% confidence interval, 7.06-13.64) and cardiovascular (relative risk, 9.73; 95% confidence interval, 7.26-13.03) conditions. CONCLUSION: This study found a strong association between previous nonbirth hospitalizations and the likelihood of severe maternal morbidity at delivery.

Examining Inequities Associated With Changes in Obstetric and Gynecologic Care Delivery During the Coronavirus Disease 2019 (COVID-19) Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic is a public health emergency requiring significant changes in obstetric and gynecologic health care delivery to minimize the risk of transmission to healthy patients and health care workers. Although these changes are necessary, they will differentially affect patients in a way that highlights and exacerbates existing inequities in health care access and outcomes. Socially vulnerable groups are already disproportionately affected by COVID-19 infection and more likely to experience severe morbidity and mortality. Some reasons for this include a limited ability to practice risk-reducing behaviors such as physical distancing, higher prevalence of chronic medical conditions, and less access to medical care. Additionally, the structural changes now taking place in health care delivery have negatively affected the ability of socially vulnerable groups to obtain necessary obstetric and gynecologic care, which may lead to poorer outcomes. As physician-leaders enact new policies to respond to the COVID-19 public health crisis, it is important to consider the potential for exacerbating existing health inequities and to be proactive in creating policies that promote equity.